Please refer to Appendix A for a complete list of the preferred practice patterns, as individual patient conditions are highly variable and other practice patterns may be applicable.

The nervous system is linked to every system of the body and is responsible for the integration and regulation of homeostasis. It is also involved in the action, communication, and higher cortical function of the body. A neurologic insult and its manifestations therefore have the potential to affect multiple body systems. To safely and effectively prevent or improve the neuromuscular, systemic, and functional sequelae of altered neurologic status in the acute care setting, the physical therapist requires an understanding of the neurologic system and the principles of neuropathology.

Body Structure and Function of the Nervous System

The nervous system is divided as follows:

• The central nervous system (CNS), consisting of the brain and spinal cord

• The peripheral nervous system, consisting of efferent and afferent nerves outside the CNS

The peripheral nervous system is divided into:

• The autonomic (involuntary) nervous system, consisting of the sympathetic and parasympathetic systems innervating the viscera, smooth muscles, and glands

• The somatic (voluntary) nervous system, consisting of efferent and afferent nerves to all parts of the body except the viscera, smooth muscles, and glands

The brain is anatomically divided into the cerebral hemispheres, diencephalon, brain stem, and cerebellum. A midsagittal view of the brain is shown in Figure 6-1, A. Figure 6-1, B shows the basal ganglia and the internal capsule. Although each portion of the brain has its own function, it is linked to other portions via tracts and rarely works in isolation. When lesions occur, disruption of these functions can be predicted. Tables 6-1 and 6-2 describe the basic structure, function, and dysfunction of the cerebral hemispheres, diencephalon, brain stem, and cerebellum.

TABLE 6-1

Structure, Function, and Dysfunction of the Cerebral Hemispheres

D, Dominant; ND, nondominant.

Data from Gilman S, Newman SW, editors: Manter and Gatz’s essentials of clinical neuroanatomy and neurophysiology, ed 7, Philadelphia, 1989, FA Davis; Kiernan JA, editor: Introduction to human neuroscience, Philadelphia, 1987, Lippincott; Marieb EN, editor: Human anatomy and physiology, ed 5, San Francisco, 2001, Benjamin-Cummings; Thelan L, Davie J, Lough M, editors: Critical care nursing: diagnosis and management, ed 2, St Louis, 1994, Mosby; Mancell EL, editor: Gray’s clinical neuroanatomy: the anatomic basis for clinical neuroscience, Philadelphia, 2011, Elsevier Saunders; O’Sullivan SB, Schmitz TJ, editors: Physical rehabilitation, ed 5, Philadelphia, 2007, FA Davis.

TABLE 6-2

Structure, Function, and Dysfunction of the Diencephalon, Brain Stem, and Cerebellum

ADH, Antidiuretic hormone; CN, cranial nerve; ICP, intracranial pressure.

FIGURE 6-1 A, Schematic midsagittal view of the brain shows the relationship between the cerebral cortex, cerebellum, spinal cord, and brainstem and the subcortical structures important to functional movement. B, Horizontal section of the cerebrum showing the basal ganglia. (A, From Cech DJ, Martin ST: Functional movement development across the life span, ed 3, St Louis, 2012, Saunders. B, From Love RJ, Webb WG, editors: Neurology for the speech-language pathologist, ed 4, Boston, 2001, Butterworth-Heinemann, p 38.)

Protective Mechanisms.

The brain is protected by the cranium, meninges, ventricular system, and blood-brain barrier.

Cranium.

The cranium encloses the brain. It is composed of eight cranial and 14 facial bones connected by sutures and contains approximately 85 foramina for the passage of the spinal cord, cranial nerves (CNs), and blood vessels.¹ The cranium is divided into the cranial vault, or calvaria (the superolateral and posterior aspects), and the cranial floor, which is composed of fossae (the anterior fossa supports the frontal lobes; the middle fossa supports the temporal lobes; and the posterior fossa supports the cerebellum, pons, and medulla).²

Meninges.

The meninges are three layers of connective tissue that cover the brain and spinal cord. The dura mater, the outermost layer, lines the skull (periosteum) and has four major folds (Table 6-3). The arachnoid, the middle layer, loosely encloses the brain. The pia mater, the inner layer, covers the convolutions of the brain and forms a portion of the choroid plexus in the ventricular system. The three layers create very important anatomic and potential spaces in the brain, as shown in Figure 6-2 and described in Table 6-4.

TABLE 6-3

Dural Folds

Falx cerebri	Vertical fold that separates the two cerebral hemispheres to prevent horizontal displacement of these structures
Falx cerebelli	Vertical fold that separates the two cerebellar hemispheres to prevent horizontal displacement of these structures
Tentorium cerebelli	Horizontal fold that separates occipital lobes from the cerebellum to prevent vertical displacement of these structures
Diaphragm sellae	Horizontal fold that separates the subarachnoid space from the sella turcica and is perforated by the stalk of the pituitary gland

Data from Wilkinson JL, editor: Neuroanatomy for medical students, ed 3, Oxford, UK, 1998, Butterworth-Heinemann.

TABLE 6-4

Dural Spaces

Epidural (extradural) space	Potential space between the skull and outer dura mater
Subdural space	Potential space between the dura and the arachnoid mater; a split in the dura contains the venous sinus
Subarachnoid space	Anatomic space between the arachnoid and pia mater containing cerebrospinal fluid and the vascular supply of the cortex

FIGURE 6-2 Coronal section of cranial meninges showing a venous sinus and dural fold. (From Young PA, Young PH: Basic clinical neuroanatomy, Philadelphia, 1997, Williams & Wilkins, p 8.)

Circulation.

The brain receives blood from the internal carotid and vertebral arteries, which are linked together by the circle of Willis, as shown in Figure 6-4. Each vessel supplies blood to a certain part of the brain (Table 6-5). The circulation of the brain is discussed in terms of a single vessel or by region (usually as the anterior or posterior circulation). There are several anastomotic systems of the cerebral vasculature that provide essential blood flow to the brain. Blood is drained from the brain through a series of venous sinuses. The superior sagittal sinus, with its associated lacunae and villi, is the primary drainage site. The superior sagittal sinus and sinuses located in the dura and scalp then drain blood into the internal jugular vein for return to the heart.

TABLE 6-5

Blood Supply of the Major Areas of the Brain

Data from Rumbaugh CL, Wang A, Tsai FY, editors: Cerebrovascular disease imaging and interventional treatment options, New York, 1995, Igaku-Shoin Medical Publishers; Moore KI, Dalley AF, editors: Clinically oriented anatomy, ed 4, Baltimore, 1999, Lippincott Williams & Wilkins; O’Sullivan SB, Schmitz TJ, editors: Physical rehabilitation, ed 5, Philadelphia, 2007, FA Davis.

FIGURE 6-4 Schematic representation of the arterial circle of Willis and accompanying veins. Ant., Anterior; art., artery; Post., posterior. (From Gonzalez EG, Meyers SJ, editors: Downey and Darling’s physiological basis of rehabilitation medicine, ed 3, Boston, 2001, Butterworth-Heinemann, p 22.)

Spinal Cord

The spinal cord lies within the spinal column and extends from the foramen magnum to the first lumbar vertebra, where it forms the conus medullaris and the cauda equina and attaches to the coccyx via the filum terminale. Divided into the cervical, thoracic, and lumbar portions, it is protected by mechanisms similar to those supporting the brain. The spinal cord is composed of gray and white matter and provides the pathway for the ascending and descending tracts, as shown in cross-section in Figure 6-5 and outlined in Table 6-6.

TABLE 6-6

Major Ascending and Descending White Matter Tracts *

Tract	Function
Fasciculus gracilis	Sensory pathway for lower-extremity and lower-trunk joint proprioception, vibration, two-point discrimination, graphesthesia, and double simultaneous stimulation
Fasciculus cuneatus	Sensory pathway for upper-extremity, upper-trunk, and neck joint proprioception, vibration, two-point discrimination, graphesthesia, and double simultaneous stimulation
Lateral spinothalamic	Sensory pathway for pain, temperature, and light touch
Ventral spinocerebellar	Sensory pathway for ipsilateral subconscious proprioception
Dorsal spinocerebellar	Sensory pathway for ipsilateral and contralateral subconscious proprioception
Lateral corticospinal (pyramidal)	Motor pathway for contralateral voluntary fine-muscle movement
Anterior corticospinal (pyramidal)	Motor pathway for ipsilateral voluntary movement
Rubrospinal (extrapyramidal)	Motor pathway for gross postural tone
Tectospinal (extrapyramidal)	Motor pathway for contralateral gross postural muscle tone associated with auditory and visual stimuli
Vestibulospinal (extrapyramidal)	Motor pathway for ipsilateral gross postural adjustments associated with head movements

^*Sensory tracts ascend from the spinal cord; motor tracts descend from the brain to the spinal cord.

Data from Gilman S, Newman SW, editors: Manter and Gatz’s essentials of clinical neuroanatomy and neurophysiology, ed 7, Philadelphia, 1989, FA Davis; Marieb EN, editor: Human anatomy and physiology, ed 5, San Francisco, 2001, Benjamin-Cummings.

FIGURE 6-5 Cross-section of the spinal cord. Ant., Anterior; Lat., lateral; Post., posterior. (From Love RJ, Webb WG, editors: Neurology for the speech-language pathologist, ed 4, Boston, 2001, Butterworth-Heinemann, p 44.)

Peripheral Nervous System

The peripheral nervous system consists of the cranial and spinal nerves and the reflex system. The primary structures include peripheral nerves, associated ganglia, and sensory receptors. There are 12 pairs of CNs, each with a unique pathway and function (sensory, motor, mixed, or autonomic). Thirty-one pairs of spinal nerves (all mixed) exit the spinal cord to form distinct plexuses (except T2 to T12). The peripheral nerves of the trunk and the upper and lower extremities are listed in Table 6-7, and the dermatomal system is shown in Figure 6-6. The reflex system includes spinal, deep tendon, stretch, and superficial reflexes and protective responses.

TABLE 6-7

Major Peripheral Nerves of the Trunk, Upper Extremity, and Lower Extremity

Data from Netter FH, editor: Atlas of human anatomy, Summit City, NJ, 1989, Ciba-Geigy; Moore KL, Dalley AF, editors: Clinically oriented anatomy, ed 4, Baltimore, 1999, Lippincott Williams & Wilkins.

FIGURE 6-6 Dermatome chart based on embryologic segments. (From Maitland GD, editor: Vertebral manipulation, ed 5, Oxford, UK, 1986, Butterworth-Heinemann, p 46.)

Autonomic Nervous System

The portion of the peripheral nervous system that innervates glands and cardiac and smooth muscle is the autonomic nervous system. The parasympathetic division is activated in times of rest, whereas the sympathetic division is activated in times of work or “fight or flight” situations. The two divisions work closely together, with dual innervation of most organs, to ensure homeostasis.

Neurologic Examination

The neurologic examination is initiated on hospital admission or in the field and is reassessed continuously, hourly, or daily, as necessary. The neurologic examination consists of patient history; observation; mental status examination; vital sign measurement; vision, motor, sensory, and coordination testing; and diagnostic testing.

Patient History

A detailed history, initially taken by the physician, is often the most helpful information used to delineate whether a patient presents with a true neurologic event or another process (usually cardiac or metabolic in nature). The history may be presented by the patient or, more commonly, by a family member or person witnessing the acute or progressive event(s) responsible for hospital admission. One common framework for organizing questions regarding each neurologic complaint, sign, or symptom is as follows 10,11:

• What is the patient feeling?

• When did the problem initially occur, and has it progressed?

• What relieves or exacerbates the problem?

• What are the onset, frequency, and duration of signs or symptoms?

In addition to the general medical record review (see Chapter 2), questions relevant to a complete neurologic history include:

• Does the problem involve loss of consciousness?

• Did a fall precede or follow the problem?

• Is there headache, dizziness, or visual disturbance?

• What are the functional deficits associated with the problem?

• Is there an alteration of speech?

• Does the patient demonstrate memory loss or altered cognition?

• Does the patient have an altered sleep pattern?

• What is the handedness of the patient? (Handedness is a predictor of brain [language] dominance.)

Observation

Data that can be gathered from close or distant observation of the patient include the following:

• Level of alertness, arousal, distress, or the need for restraint

• Body position

• Head, trunk, and extremity posture, including movement patterns

• Amount and quality of active movement

• Amount and quality of interaction with the environment or family members

• Degree of ease or difficulty with activities of daily living

• Presence of involuntary movements, such as tremor

• Eye movement(s)

• Presence of hemibody or hemispace neglect

• Presence of muscle atrophy

• Respiratory rate and pattern

• Facial expression and symmetry

The therapist should correlate these observations with other information from the chart review and other health care team members to determine:

1. If the diagnosis is consistent with the physical presentation,

2. What types of commands or tone of voice to use,

3. How much assistance is needed, and

4. How to prioritize the portions of the physical therapy evaluation.

Mental Status Examination

The mental status examination includes assessment of level of consciousness, cognition, emotional state, memory, and speech and language ability.

Level of Consciousness

Consciousness consists of arousal and the awareness of self and environment, including the ability to interact appropriately in response to any normal stimulus.¹² Coma is often considered the opposite of consciousness. Table 6-8 describes the different states of consciousness. Evaluating a patient’s level of consciousness is important because it serves as a baseline to monitor stability, improvement, or decline in the patient’s condition. It also helps to determine the severity and prognosis of neurologic insult or disease state, thus directing the medical plan of care.

TABLE 6-8

Normal and Abnormal States of Consciousness

Physical Therapy Implications.

Time of day, fatigue, and side effects of medication are factors that can cause variable levels of alertness or participation in physical therapy. The documentation of these factors is important for communication among the health care team and for the rehabilitation screening process. A progressive intensity of stimuli should be used to arouse a patient with decreased alertness or level of consciousness. For example, call the patient’s name in a normal tone of voice before using a loud tone of voice, or tap the patient’s shoulder before rubbing the shoulder. Changes in body position, especially the transition from a recumbent position to sitting upright, can also be used to stimulate increased alertness. Other stimuli to increase alertness include daylight, radio or television sound, or a cold cloth on the forehead.

Glasgow Coma Scale.

The Glasgow Coma Scale (GCS) is a widely accepted measure of level of consciousness and responsiveness and is described in Table 6-9. The GCS evaluates best eye opening (E), motor response (M), and verbal response (V). To determine a patient’s overall GCS, add each score (i.e., E + M + V). Scores range from 3 to 15. A score of 8 or less signifies coma.¹³

TABLE 6-9

Glasgow Coma Scale

Data from Teasdale G, Jennett B: Assessment of coma and impaired consciousness: a practical scale, Lancet 2:81, 1974.

Calculation of the GCS usually occurs at regular intervals. The GCS should be used to confirm the type and amount of cueing needed to communicate with a patient, determine what time of day a patient is most capable of participating in physical therapy, and delineate physical therapy goals.

Cognition

Cognitive testing includes the assessment of attention, orientation, memory, abstract thought, and the ability to perform calculations or construct figures. General intelligence and vocabulary are estimated with questions regarding history, geography, or current events. Table 6-10 lists typical methods of testing the components of cognition.

TABLE 6-10

Tests of Cognitive Function

Cognitive Function	Definition	Task
Attention	Ability to attend to a specific stimulus or task	Repetition of a series of numbers or letters Spelling words forward and backward
Orientation	Ability to orient to person, place, and time	Identify name, age, current date and season, birth date, present location, town, etc.
Memory	Immediate recall Short-term memory Long-term memory	Recount three words after a few seconds Recount words (after a few minutes) or recent events Recount past events
Calculation	Ability to perform verbal or written mathematical problems	Add, subtract, multiply, or divide whole numbers
Construction	Ability to construct a two- or three-dimensional figure or shape	Draw a figure after a verbal command or reproduce a figure from a picture
Abstraction	Ability to reason in an abstract rather than a literal or concrete fashion	Interpret proverbs Discuss how two objects are similar or different
Judgment	Ability to reason (according to age and lifestyle)	Demonstrate common sense and safety

Data from Bickley LS, Hoekelman RA, editors: Bates’ guide to physical examination and history taking, ed 7, Philadelphia, 1999, Lippincott Williams & Wilkins.

Clinical Tip

A & O × 3 is a common abbreviation for alert and oriented to person, place, and time. The number may be modified to reflect the patient’s orientation (e.g., A & O × 1 [self]). A & O × 4 may also be used to identify that the patient is oriented to the situation.

Emotional State

Emotional state assessment entails observation and direct questioning to ascertain a patient’s mood, affect, perception, and thought process, as well as to evaluate for behavioral changes. Evaluation of emotion is not meant to be a full psychiatric examination; however, it provides insight as to how a patient may complete the cognitive portion of the mental status examination.¹⁴

It is important to note that a patient’s culture may affect particular emotional responses. Patients who recently have had a stroke or have a history of stroke, for example, can be emotionally labile depending on the site of the lesion. This can be quite stressful for patients because they feel that they have little control over their emotions.

Speech and Language Ability

The physician should perform a speech and language assessment as soon as possible according to the patient’s level of consciousness. The main goals of this assessment are to evaluate the patient’s ability to articulate and produce voice and the presence, extent, and severity of aphasia.¹⁵ These goals are achieved by testing comprehension and repetition of spoken speech, naming, quality and quantity of conversational speech, and reading and writing abilities.¹⁵

A speech-language pathologist is often consulted to perform a longer, more in-depth examination of cognition, speech, and swallow using standardized tests and skilled evaluation of articulation, phonation, hearing, and orofacial muscle strength testing. The physical therapist should be aware of, and use, as appropriate, the speech-language pathologist’s suggestions for types of commands, activity modification, and positioning as related to risk of aspiration.

Clinical Tip

Be sure to allow the patient ample time to respond to a command or a question. Slowed response time can be mistaken for aphasia.

Vital Signs

The brain is the homeostatic center of the body; therefore, vital signs are an indirect measure of neurologic status and the body’s ability to perform basic functions, such as respiration and temperature control.

Blood pressure, heart rate, respiratory rate and pattern (see Table 4-3), temperature, and other vital signs from invasive monitoring (see Table 18-4) are assessed continuously or hourly to determine neurologic and hemodynamic stability.

Physical Therapy Implications

The therapist should be aware of blood pressure parameters determined by the physician for the patient with neurologic dysfunction. These parameters may be set greater than normal to maintain adequate perfusion to the brain or lower than normal to prevent further injury to the brain.

It is important for the therapist to be aware of vital sign trends (especially blood pressure) in the neurologic patient over the course of the day(s). An increase or decrease in blood pressure over time may be intentional and related to medication changes, or it may be unrelated to medication changes. A change unrelated to medication (or intravenous fluid administration) may be related to neurologic decline due to increased intracranial pressure (ICP). Trends in vital signs should be used by the clinician to determine the safety of physical therapy intervention.

Cranial Nerves

Cranial nerve (CN) testing provides information about the general neurologic status of the patient and the function of the special senses. The results assist in the differential diagnosis of neurologic dysfunction and may help in determining the location of a lesion. CNs I through XII are tested on admission, daily in the hospital, or when there is a suspected change in neurologic function (Table 6-11).

TABLE 6-11

Origin, Purpose, and Testing of the Cranial Nerves

CN, Cranial nerve; LMN, lower motor neuron; UMN, upper motor neuron.

^*Rarely tested.

Data from Lindsay KW, Bone I, Callander R, editors: Neurology and neurosurgery illustrated, ed 2, Edinburgh, UK, 1991, Churchill Livingstone; Marieb EN, editor: Human anatomy and physiology, ed 5, San Francisco, 2001, Benjamin-Cummings; McNeill ME, editor: Neuroanatomy primer, Baltimore, 1997, Lippincott Williams & Wilkins; O’Sullivan SB, Schmitz TJ, editors: Physical rehabilitation, ed 5, Philadelphia, 2007, FA Davis.

Vision

Vision testing is an important portion of the neurologic examination because alterations in vision can indicate neurologic lesions, as illustrated in Figure 6-7. In addition to the visual field, acuity, reflexive, and ophthalmoscopic testing performed by the physician during CN assessment, the pupils are further examined for size and equality, shape, and reactivity. PERRLA is an acronym that describes pupil function: pupils equal, round, and reactive to light and accommodation.

FIGURE 6-7 Visual pathway with lesion sites and resulting visual field defects. The occipital lobe has been cut away to show the medial aspect and the calcarine sulci. (From Love RJ, Webb WG, editors: Neurology for the speech-language pathologist, ed 4, Boston, 2001, Butterworth-Heinemann, p 103.)

Note any baseline pupil changes, such as those associated with cataract repair (keyhole shape). If the patient’s vision or pupil size or shape changes during physical therapy intervention, discontinue the treatment and notify the nurse or physician immediately.

• Size and equality: Pupil size is normally 2 to 4 mm or 4 to 8 mm in diameter in the light and dark, respectively.¹⁶ The pupils should be of equal size, although up to a 1-mm difference in diameter can normally occur between the left and right pupils.¹⁷

• Shape: Pupils are normally round but may become oval or irregularly shaped with neurologic dysfunction.

• Reactivity: Pupils normally constrict in response to light, as a consensual response to light shone in the opposite eye or when fixed on a near object. Conversely, pupils normally dilate in the dark. Constriction and dilation occur briskly under normal circumstances. A variety of deviations of pupil characteristics can occur. Pupil reactivity can be tested by shining a light directly into the patient’s eye. Dilated, nonreactive (fixed), malpositioned, or disconjugate pupils can signify very serious neurologic conditions (especially oculomotor compression, increased ICP, or brain herniation).¹⁷

Clinical Tip

For a patient with diplopia (double vision), a cotton or gauze eye patch can be worn temporarily over one eye to improve participation during physical therapy sessions.

The presence of nystagmus during the visual exam should also be noted. Nystagmus is an involuntary rhythmic movement of the eyes that may be present at rest or occur with eye or head movements.¹⁸ Nystagmus can be the result of vestibular dysfunction, a cerebellar lesion, or an imbalance in the reflex activity coordinating the two. While observing nystagmus, it is important to note the orientation (vertical versus horizontal), direction (right versus left), and head motions that increase the nystagmus. This will aid the clinician in determining the cause. Nystagmus involving the tracts/reflexes between the vestibular system and cerebellum is usually horizontal in nature and more pronounced when looking to the side of the lesion.¹⁸ Vertical nystagmus is usually present with lesions involving the anterior vermis of the cerebellum or medulla and indicates a poor prognosis for recovery. Spontaneous (at rest) nystagmus is most often observed after an acute unilateral insult to the vestibular system.⁷

Clinical Tip

One treatment technique to reduce nystagmus or associated vertigo during mobility is to use gaze stabilization. Direct the patient to focus on an object during transfers or ambulation.

Motor Function

The evaluation of motor function consists of strength, tone, and reflex testing.

Strength Testing

Strength is the force output of a contracting muscle directly related to the amount of tension that it can produce.¹⁹ Strength can be graded in the following ways in the acute care setting:

• Graded 0-5/0-N (normal) with manual muscle testing

• Graded as strong or weak with resisted isometrics

• Graded by the portion of a range of motion in which movement occurs (e.g., hip flexion through one fourth of available range)

• Graded functionally

The manner in which muscle strength is tested depends on the patient’s ability to follow commands, arousal, cooperation, and activity tolerance, as well as on constraints on the patient, such as positioning, sedation, and medical equipment. If it is not possible to grade strength in any of the described ways, then only the presence, frequency, and location of spontaneous movements are noted instead.

Muscle Tone

Muscle tone has been described in a multitude of ways; however, neither a precise definition nor a quantitative measure has been determined.²⁰ It is beyond the scope of this book to discuss the various definitions of tone, including variants such as clonus and tremor. For simplicity, muscle tone is discussed in terms of hypertonicity, hypotonicity, or dystonia. Hypertonicity, an increase in muscle contractility, includes spasticity (velocity-dependent increase in resistance to passive stretch) and rigidity (increased uniform resistance that is present throughout the whole range of motion and is independent of velocity) secondary to a neurologic lesion of the CNS or upper motor neuron system.⁷ Hypotonicity, a decrease in muscle contractility, includes flaccidity (diminished resistance to passive stretching and tendon reflexes)²¹ from a neurologic lesion of the lower motor neuron system (or as in the early stage of spinal cord injury [SCI] known as spinal shock). Dystonia, a hyperkinetic movement disorder, is characterized by disordered tone and involuntary movements involving large portions of the body resulting from a lesion in the basal ganglia (as in Parkinson’s disease with excessive L-dopa therapy).⁷ Regardless of the specific definition of muscle tone, clinicians agree that muscle tone may change according to a variety of factors, including stress, febrile state, pain, body position, medical status, medication, CNS arousal, and degree of volitional movement.⁷

Muscle tone can be evaluated qualitatively in the following ways:

• Passively as mild (i.e., mild resistance to movement with quick stretch), moderate (i.e., moderate resistance to movement, even without quick stretch), or severe (i.e., resistance great enough to prevent movement of a joint)²²

• Passively or actively as the ability or inability to achieve full joint range of motion

• Actively as the ability to complete functional mobility and volitional movement

• As abnormal decorticate (flexion) or decerebrate (extension) posturing. (Decortication is the result of a hemispheric or internal capsule lesion that results in a disruption of the corticospinal tract.¹⁷ Decerebration is the result of a brain stem lesion and is thus considered a sign of deteriorating neurologic status.¹⁷ A patient may demonstrate one or both of these postures.)

Muscle tone and spasticity can also be evaluated objectively using the following scales:

• Modified Ashworth Scale as described in Table 6-12. This scale has been considered the “gold standard” of measuring muscle tone due to initial studies showing high interrater (0.84) and intrarater (0.83) reliability.²³ However, more recent studies have had less favorable results, showing moderate reliability.^24–26

TABLE 6-12

Modified Ashworth Scale for Grading Abnormal Tone

Grade	Description
0	No increase in muscle tone.
1	Slight increase in muscle tone, manifested by a slight catch and release or by minimal resistance at the end of the range of motion when the affected part(s) is moved in flexion or extension.
1+	Slight increase in muscle tone, manifested by a catch, followed by minimal resistance throughout the remainder (less than half) of the range of motion.
2	More marked increased in muscle tone through most of the range of motion, but affected part(s) easily moved.
3	Considerable increase in muscle tone; passive movement difficult.
4	Affected part(s) rigid in flexion and extension.

From Bohannon RW, Smith MB: Interrater reliability of a Modified Ashworth Scale of Muscle Spasticity, Phys Ther 67:206, 1987.

• Modified Tardieu Scale as described in Table 6-13. The Tardieu Scale was developed by Tardieu in 1954^26a (the patient is in the supine position) and modified by Boyd and Graham in 1999^26b (the patient is in supine, sitting, or standing, depending on the joint tested). This scale measures the quality of muscle reaction to passive stretch at three different velocities. Not only is the muscle reaction quantified (as in the Modified Ashworth Scale), but it also controls for the velocity of the stretch and measures the angle at which the catch, or clonus, occurs.^26b This scale has been shown in recent studies to be a more accurate measure of spasticity than the Modified Ashworth Scale.^27,28

TABLE 6-13

Tardieu Scale for Grading Spasticity

Grade	Description
0	No resistance throughout the course of movement.
1	Slight resistance throughout the course of movement, but no clear catch.
2	Clear catch at a precise angle, interrupting the movement, followed by release.
3	Fatigable clonus with less than 10 seconds when maintaining the pressure and appearing at a precise angle.
4	Unfatigable clonus with more than 10 seconds when maintaining the pressure and appearing at a precise angle.
5	Joint is immovable.

Measurements are taken at three different velocities: V1: As slow as possible (slower than the natural drop of the limb segment under gravity); V2: Speed of limb segment falling under gravity; V3: As fast as possible (faster than the natural drop of the limb segment under gravity).

Responses are recorded at each velocity as X/Y, with X indicating the 0 to 5 rating, and Y indicating the degree of angle at which the muscle reaction occurs. Refer to Appendix 6-A for an example of a scoring sheet for this particular scale.

From Tardieu G, Shentoub S, Delarue R: A la recherché d’une technique de mesure de la spasticite. Revue Neurologique. Research on a technic for measurement of spasticity, Rev Neurol (Paris) 91:143-144, 1954.

Reflexes

A reflex is a motor response to a sensory stimulus and is used to assess the integrity of the motor system in the conscious or unconscious patient. The reflexes most commonly tested are deep tendon reflexes (DTRs). A DTR should elicit a muscle contraction of the tendon stimulated. Table 6-14 describes DTRs according to spinal level and expected response. DTR testing should proceed in the following manner:

TABLE 6-14

Deep Tendon Reflexes of the Upper and Lower Extremities

Reflex	Spinal Level	Normal Response
Biceps	C5	Elbow flexion
Brachioradialis	C6	Elbow flexion
Triceps	C7	Elbow extension
Patellar	L4	Knee extension
Posterior tibialis	L5	Plantar flexion and inversion
Achilles	S1	Plantar flexion

1. The patient should be sitting or supine and as relaxed as possible.

2. The joint to be tested should be in midposition to stretch the tendon.

3. The tendon is then directly tapped with a reflex hammer. Both sides should be compared.

Reflexes are typically graded as present (normal, exaggerated, or depressed) or absent. Reflexes can also be graded on a scale of 0 to 4, as described in Table 6-15. Depressed reflexes signify lower motor neuron disease or neuropathy. Exaggerated reflexes signify upper motor neuron disease, or they may be due to hyperthyroidism, electrolyte imbalance, or other metabolic abnormalities.²⁹

TABLE 6-15

Deep Tendon Reflex Grades and Interpretation

Grade	Response	Interpretation
0	No response	Abnormal
1+	Diminished or sluggish response	Low normal
2+	Active response	Normal
3+	Brisk response	High normal
4+	Very brisk response, with or without clonus	Abnormal

Data from Bickley LS, Hoekelman RA: Bates’ guide to physical examination and history taking, ed 7, Philadelphia, 1999, Lippincott Williams & Wilkins.

Clinical Tip

The numeric results of DTR testing may appear in a stick figure drawing in the medical record. The DTR grades are placed next to each of the main DTR sites. An arrow may appear next to the stick figure as well. Arrows pointing upward signify hyperreflexia; conversely, arrows pointing downward signify hyporeflexia.

A superficial reflex should elicit a muscle contraction from the cornea, mucous membrane, or area of the skin that is stimulated. The most frequently tested superficial reflexes are the corneal (which involve CNs V and VII), gag and swallowing (which involve CNs IX and X), and perianal reflexes (which involve S3 to S5). These reflexes are evaluated by physicians and are graded as present or absent. Superficial reflexes may also be recurrent primitive reflexes that are graded as present or absent.

The most commonly tested cutaneous reflex is the Babinski sign. A positive (abnormal) Babinski sign is great-toe extension with splaying of the toes in response to stroking the lateral plantar surface of the foot with the opposite end of a reflex hammer. It indicates corticospinal tract damage, as seen in spinal cord injury, stroke, and multiple sclerosis.³⁰

Clinical Tip

A positive Babinski sign may be noted in a patient’s chart as “upgoing toe(s) on the right (or left).”

Other primitive reflexes that can be tested are flexor withdrawal and plantar or palmar grasp. These are all reflexes normally seen in infants that become integrated at an early age. The presence of any of these three reflexes in an adult is abnormal and usually indicates significant upper motor neuron lesion or brain injury. If the patient does squeeze the clinician’s hand while the clinician is testing for the palmar grasp reflex, then the clinician should also ask the patient to release his or her hand: if the patient releases the hand it will be a better indicator as to whether the patient is truly following commands.

Sensation

Sensation testing evaluates the ability to sense light touch, proprioception, pressure, temperature, vibration sense, and pain. For each modality, the face, neck, trunk, and extremities are tested bilaterally, proceeding in a dermatomal pattern (see Figure 6-6). For more reliable sensation testing results, the patient should be asked to close his or her eyes or look away from the area being tested. Table 6-16 outlines the method of sensation testing by stimulus.

TABLE 6-16

Sensation Testing

Sensation	Modality and Method
Light touch	Apply light touch with the finger, a cotton ball, or washcloth over the extremities or trunk. The patient is asked to identify if there is a stimulus present and the location of the stimulus.
Pain	Touch a pin or pen cap over the extremities or trunk. Ask the patient to distinguish between dull (pen cap) and sharp (the pin) stimuli.
Pressure	Using the therapist’s fingertip, apply pressure on the skin surface that is firm enough to indent the skin and stimulate the deep receptors. The patient is asked to identify if there is a stimulus present.
Proprioception	Lightly grasp the distal interphalangeal joint of the patient’s finger or great toe, and move the joint slowly up and down. Ask the patient to state in which direction the joint is moved. Test distal to proximal (e.g., toe to ankle to knee).
Vibration	Activate a tuning fork and place on a bony prominence. Ask the patient to state when the vibration slows and stops. Proceed distal to proximal.
Temperature	Place test tubes filled with warm or cold water on the area of the patient’s body to be tested. Ask the patient to state the temperature. (Rarely done in the acute care setting.)
Stereognosis	Place a familiar object in the patient’s hand and ask the patient to identify it.
Two-point discrimination	Place two-point caliper or drafting compass on area to be tested. Ask the patient to distinguish whether it has one or two points.
Graphesthesia	Trace a letter or number in the patient’s open palm and ask the patient to state what was drawn.
Double simultaneous stimulation	Simultaneously touch two areas on the same side of the patient’s body. Ask patient to locate and distinguish both points.

Data from Lindsay KW, Bone I, Callander R, editors: Neurology and neurosurgery illustrated, ed 2, Edinburgh, UK, 1991, Churchill Livingstone; Gilman S, Newman SW, editors: Manter and Gatz’s essentials of clinical neuroanatomy and neurophysiology, ed 7, Philadelphia, 1989, FA Davis; Hickey JV, editor: The clinical practice of neurological and neurosurgical nursing ed 4, Philadelphia, 1997, Lippincott.

< div class='tao-gold-member'>

Only gold members can continue reading. Log In or Register to continue